Hospitals launch major infection control efforts

Harrington Hospital's newest weapon in the fight against dangerous bacteria is a light-flashing robot.

The machine bathes patient rooms in ultraviolet light, the beams penetrating the DNA of bacteria cells and rendering them inactive. It promises to kill germs that disinfectants like bleach leave behind. And when bacteria are left behind, they can grow and enter the bodies of sick patients lying in hospital beds.

"We plan on using this extensively," Harrington's infection preventionist, Sue Valentine, said of the more than $70,000 machine, which is scheduled to arrive in early 2014. "This gives us another level of assurance that we've done everything we can to get that room ready for the next patient."

In Central Massachusetts and beyond, hospitals big and small are taking new steps to keep patients from acquiring dangerous, sometimes deadly, infections while receiving care. Their efforts come as new reporting requirements publicly expose their infection rates for the first time, and as health insurers increasingly pay hospitals not just for the quantity of care they provide, but the quality.

The Massachusetts Hospital Association runs a website dedicated to patient safety. Hospitals have staff dedicated to fighting infections. And regulators have started watching their efforts more closely.

The breadth of infection control practices today represents a major shift from the days when infections were considered a normal part of the business of providing health care.

There is general consensus that many, if not most, hospital infections are preventable. But hospital executives bristle at the notion that infections are tantamount to medical errors. Sometimes, all the right steps are followed, they say, and patients still develop infections.

Rates of some types of infections have declined in recent years, hospital-acquired infections remain a common, sometimes fatal, problem.

It is also hugely expensive, costing the country tens of billions of dollars every year. The Centers for Disease Control and Prevention estimates that preventing just 20 percent of infections nationwide could save $5.7 billion to $6.8 billion annually.

"It's not just a big medical center problem," Ms. Valentine said. "It also can affect community hospitals."

Harrington, a 114-bed hospital in Southbridge, reported just one infection in four years, according to the most recent state reports, which count infections acquired through large intravenous catheters and certain surgical site infections. The state Department of Public Health does not monitor urinary tract infections, though they are the most common type of infection patients pick up at hospitals.

Harrington's mostly clean record is the result of its infection control practices, but also has to do with the types of patients seen there — and perhaps, some luck.

Like its bigger peers, Harrington trains workers to follow simple but significant measures, like handwashing. This has become even more important with the growth of clostridium difficile, an intestinal infection that causes severe diarrhea and can be fatal. After more patients started arriving at the hospital with C. difficile symptoms, posing a risk to patients already at the hospital, Harrington taught employees about the risks of the disease and implemented new cleaning procedures. "Our focus has become identifying these people very early on and making sure they get treatment," Ms. Valentine said.

At the campuses of UMass Memorial Medical Center in Worcester, there is a dispenser of hand sanitizer outside every patient room. Health care workers are not allowed to enter or leave a patient room without rubbing their hands with antibacterial foam. Even visitors are required to clean their hands before seeing certain patients.

Nurse Ellen T. Smith, who works 12-hour shifts in a medical intensive care unit, guessed that she washes or sanitizes her hands at least 100 times a day. "My hands are so dry right now," she said. "They want you foaming in and out even if you don't touch anything."

Last year, UMass Memorial enlisted medical students to secretly watch hospital workers and see if they were washing their hands routinely. The results were far from perfect. So the hospital developed an "action plan," which included educating employees and changing the signs that remind people to wash their hands.

Some of the responsibility falls on patients; they are encouraged to ask their doctors and nurses: Did you wash your hands?

"It's empowering the patient with no repercussions," said Dr. Margaret M. Hudlin, chief of quality at UMass Memorial Medical Center.

At St. Vincent Hospital, Dr. Anthony L. Esposito, head of infection control, sometimes observes surgeries to see if any errant bacteria may have wandered into an operating room on a piece of jewelry and to watch for any "odd behavior, anything that may represent a break in the standard."

Before surgery, many patients are tested and given antibiotics for Methicillin-resistant Staphylococcus aureus, or MRSA, a common bacteria that can be harmful if it enters the bloodstream.

To prevent patients from being harmed, hospitals also have adopted something common in other industries: the checklist.

They use checklists for surgeries, when patients are transferred from one unit or doctor to another, when they're inserting catheters and other procedures.

"More and more, it's getting deeper into the culture," Dr. Hudlin said. "There are certain things that we really need to have a format to make sure that we've done all the things we need to do."

UMass Memorial, which has a high rate of hospital-acquired urinary tract infections compared to the national benchmark, developed new procedures for preventing UTIs about two years ago, Dr. Hudlin said. It includes a checklist of 10 reasons a patient, unable to use a bathroom, may need a urinary catheter. If a physician doesn't check off one of those 10 reasons, the patient goes without a catheter, even if this means the patient's bed linens will have to be changed more frequently.

Daily, doctors and nurses monitor the catheter and determine if it needs to stay in place. Similar procedures are followed for central lines, catheters that are four times as big as normal IV tubes and connect to a vein very close to the heart. Any germs that touch the line — from a piece of medical equipment, a doctor's hands or from the patient's own skin — can cause serious harm if they seep into the bloodstream.

For this reason hospitals have tried to reduce their use of central lines altogether.

"We consider any device that we enter into a patient as a potential portal for infection, so we don't want to be using those devices any longer than we need to," said Patty Ellis, vice president of quality and patient safety at St. Vincent Hospital.

The 270-bed hospital uses a checklist for patients with central lines, modeled on best practices compiled by the Centers for Disease Control and Prevention and the Institute for Healthcare Improvement, a private group that helps hospitals with infection prevention. A committee discusses infections monthly and reviews prevention strategies a couple times a year.

Still, six people at St. Vincent contracted central line infections last year, according to data provided by the hospital. It was a jump up from two infections in 2011 and one in 2010.

One of the disconcerting things about central line infections — which can be deadly — is that they can be hard to detect. Patients generally develop a fever and sweat, and their white blood cell count climbs. But these are generic symptoms that could be caused by many different conditions.

If an infection is suspected, a sample of the patient's blood is sent for a culture. The patient is given antibiotics to fight the infection, but it takes days for the culture to help doctors identify the bacteria that's causing problems — and the medication that is likely to help.

UMass Memorial Medical Center, the biggest hospital in Central Massachusetts, with 781 beds, has made strides in reducing central line infections.

They fell 89 percent from 2004 to 2011, according to a hospital report, but these infections are still the ones Dr. Richard T. Ellison III, head of infection control, worries about most. To reduce these serious infections, UMass Memorial began using a checklist to standardize procedures across its seven ICUs.

One way infections can occur is if the dressing covering the part of the skin where the line enters the body slips. When infection preventionists realized this was happening at UMass Memorial, they designed a guide for how to apply dressings on patients of different shapes and sizes.

"People's necks are different," Dr. Ellison said. "We put together a set of pictures of how to do dressings for different kinds of necks."

Staff learned the new procedures. And every time an infection occurred, they talked about whether it could have been prevented.

The job of infection preventionists is rarely simple and constantly evolving. Doctors sometimes have to weigh one harm against another.

An example: patients who need urinary catheters can take antibiotics to prevent urinary tract infections, but those same antibiotics, by killing off good bacteria as well as bad, can put the patient at risk of developing C. difficile.

At the front lines of caring for the sick, Ms. Smith, an ICU nurse for 15 years, said infection prevention requires vigilance. She is responsible for one or two patients at a time, often patients with serious ailments like kidney or liver failure.

She checks on each patient's vital signs hourly, sometimes more. She turns them so they don't develop bed sores.

"We're constantly assessing and reassessing things," she said.

Hospital executives say they're committed to improving the quality of health care. But Dr. Ashish K. Jha, a professor at Harvard School of Public Health who studies patient safety issues, sees much room for improvement.

He said infection control still is not as much of a priority for hospitals as are other issues more directly tied to their bottom lines.

"This is not in the top three (priorities)," he said. "This is not in the top five. Because it doesn't have any real financial threat to them."